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Addiction Medicine: Closing the Gap between Science and Practice

(lu) #1

  • I. Introduction and Executive Summary ..................................................................................... Foreword and Accompanying Statement by Drew Altman, PhD i

    • The CASA Columbia Study.................................................................................................

    • Key Findings ........................................................................................................................

      • Addiction Is a Brain Disease..........................................................................................

        • the Development of Addiction ................................................................................. As with Other Health Conditions, There Are Clear Risk Factors for



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

      • Addiction Can Be a Chronic Disease.............................................................................

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

        • Risky Use and Addiction ......................................................................................... Multiple Addictive Substances and Behaviors Frequently Are Involved in



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

        • Addressing this Disease ........................................................................................... Physicians and Other Health Care Providers Should Be on the Front Line for

        • Risky Substance Use and Forestalling Addiction .................................................... Screening and Intervention Are Effective at Addressing



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

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

        • Non-Medical Approach to Addiction Care ............................................................ Public Attitudes about Addiction Treatment Reflect the Prevailing



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

        • Criminal Justice System ......................................................................................... Most Referrals to Publicly Funded Treatment Come from the



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

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

      • The Spending Gap........................................................................................................

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

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

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



    • Recommendations and Next Steps.....................................................................................

      • Reform Health Care Practice .......................................................................................

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





  • II. What Is Addiction? .................................................................................................................

    • Addiction Is a Brain Disease..............................................................................................

    • The Risk Factors for Addiction..........................................................................................

      • Genetic Risks ...............................................................................................................

      • Biological Risks ...........................................................................................................

      • Psychological Risks .....................................................................................................

      • Environmental Risks ....................................................................................................

      • Early Initiation of Use ..................................................................................................



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

    • Addiction Can Be a Chronic Disease.................................................................................

    • Models for Understanding Addiction ................................................................................

    • Evolving Approaches to Addressing Addiction ................................................................

    • Defining the Terms ............................................................................................................

      • The Continuum of Substance Use................................................................................



    • Public Attitudes about Addiction .......................................................................................

      • Perceived Causes of Addiction ....................................................................................





  • III. Prevalence and Consequences ..............................................................................................

    • Defining the Problem .........................................................................................................

    • Risky Substance Users .......................................................................................................

      • Risky Tobacco Use ......................................................................................................

      • Risky Alcohol Use .......................................................................................................

      • Risky Illicit Drug Use ..................................................................................................

      • Risky Use of Controlled Prescription Drugs ...............................................................



    • Addiction............................................................................................................................

    • Special Populations ............................................................................................................

      • Pregnant Women ..........................................................................................................

      • Adolescents and Young Adults ....................................................................................

      • Older Adults .................................................................................................................

      • Co-Occurring Disorders ...............................................................................................

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

      • Involvement in the Justice System ...............................................................................



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

      • Tobacco ........................................................................................................................

      • Alcohol .........................................................................................................................

      • Illicit Drugs ..................................................................................................................

      • Controlled Prescription Drugs .....................................................................................





  • IV. Screening and Early Intervention ........................................................................................

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

      • Childhood and Adolescence ........................................................................................

      • Young Adulthood.........................................................................................................

      • Middle and Later Adulthood ........................................................................................



    • Attending to Co-Occurring Conditions ..............................................................................

    • Patient Education and Motivation

    • Screening............................................................................................................................

      • Laboratory Tests ..........................................................................................................



    • Brief Interventions and Treatment Referrals .....................................................................

      • Tobacco ........................................................................................................................

      • Alcohol and Other Drugs .............................................................................................



    • Effectiveness of Screening and Brief Interventions...........................................................

      • Tobacco ........................................................................................................................

      • Alcohol .........................................................................................................................

      • Other Drugs ..................................................................................................................



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

      • Primary Care ................................................................................................................

      • Emergency and Trauma Care.......................................................................................

      • Health Care for Pregnant Women ................................................................................

      • Mental Health Care ......................................................................................................

      • Dental Care ..................................................................................................................

      • Pharmacies ...................................................................................................................

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

      • Justice Settings .............................................................................................................

      • The Workplace .............................................................................................................

      • Government-Funded Social Service Systems ..............................................................



    • Barriers to Effective Implementation of Screening and Brief Interventions

      • Insufficient Training ....................................................................................................

      • Competing Priorities/Insufficient Resources ...............................................................

      • Inadequate Screening Tools .........................................................................................





  • V. Treatment and Management of Addiction ...........................................................................

    • A Comprehensive Approach to Treatment ........................................................................

    • Assessment .........................................................................................................................

    • Stabilization .......................................................................................................................

      • Cessation of Use ..........................................................................................................

      • Detoxification ..............................................................................................................



    • Acute Care .........................................................................................................................

      • Pharmaceutical Therapies ............................................................................................

      • Psychosocial Therapies ..............................................................................................

      • Combined Therapies ..................................................................................................

      • Nutrition and Exercise ...............................................................................................



    • Chronic Disease Management .........................................................................................

      • Medically Supervised Disease Management .............................................................

      • Case Management ......................................................................................................



    • Support Services ..............................................................................................................

      • Mutual Support Services ............................................................................................

      • Auxiliary Support Services ........................................................................................



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

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

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

      • Perceptions of the Goals of Treatment .......................................................................

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

      • Perceptions of the Effectiveness of Treatment ..........................................................





  • VI. Tailored Treatment for Special Populations .....................................................................

    • Co-o ccurring Medical Disorders......................................................................................

    • Co-occurring Mental Health Disorders ............................................................................

      • Tobacco Cessation .....................................................................................................

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



    • Adolescents ......................................................................................................................

      • Tobacco Cessation .....................................................................................................

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



    • Women

      • Pregnant Women ........................................................................................................



    • Older Adults .....................................................................................................................

    • Racial and Ethnic Minorities ...........................................................................................

    • Individuals of Minority Sexual Orientation .....................................................................

    • Veterans and Active Duty Military ..................................................................................

    • Individuals Involved in the Justice System ......................................................................

      • Juvenile Offenders .....................................................................................................

      • Adult Corrections .......................................................................................................





  • VII. The Addiction Treatment Gap .........................................................................................

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

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

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

      • Regional Variations in the Treatment Gap ................................................................



    • Sources of Funding for Addiction Treatment ..................................................................

      • Privately-Funded Treatment ......................................................................................

      • Publically-Funded Treatment.....................................................................................

      • Trends in Spending on Addiction Treatment .............................................................

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



    • Treatment Admissions .....................................................................................................

    • Treatment Referrals and Venues ......................................................................................

    • Treatment Completion .....................................................................................................

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

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

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



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

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

      • Misunderstanding of the Disease ...............................................................................

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

      • Privacy Concerns .......................................................................................................

      • Cost

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

      • Limited Availability of Services ................................................................................

      • Insufficient Social Support ........................................................................................

      • Conflicting Time Commitments ................................................................................

      • Negative Perceptions of the Treatment Process.........................................................

      • Legal Barriers.............................................................................................................



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

      • Individuals with Co-Occurring Conditions ................................................................

      • Pregnant and Parenting Women.................................................................................

      • Adolescents ................................................................................................................

      • Older Adults ...............................................................................................................

      • The Homeless.............................................................................................................

      • Veterans and Active Duty Military ............................................................................

      • Rural Populations .......................................................................................................

      • Native Americans.......................................................................................................





  • VIII. The Spending Gap ............................................................................................................

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

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

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



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

      • Screening and Early Intervention ...............................................................................

      • Addiction Treatment and Disease Management ........................................................



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

      • Parity Laws ................................................................................................................

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

        • Impede Comprehensive Addiction Care ................................................................. Gaps in Coverage within Public and Private Insurance Plans Continue to







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

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

      • Addiction Treatment ..................................................................................................... Licensing and Credentialing Requirements for Individuals who Provide

        • Medical Professionals ................................................................................................

        • Mental Health Professionals ......................................................................................

        • Acupuncturists ...........................................................................................................

        • Addiction Counselors.................................................................................................



      • Programs and Facilities ................................................................................................. Licensure, Certification and Accreditation Requirements for Addiction Treatment

        • State Licensing Requirements....................................................................................

        • Federal Regulatory Requirements ..............................................................................

        • Accreditation Requirements.......................................................................................

        • Professional Staffing Requirements ...........................................................................

        • Treatment Service Requirements ...............................................................................

        • Quality Assurance Requirements ...............................................................................







  • X. The Evidence-Practice Gap ..................................................................................................

    • with the Science and Evidence-Based Care .................................................................. Current Approaches to Risky Substance Use and Addiction Are Inconsistent

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

      • Assessment, Stabilization and Acute Treatment ........................................................

      • Tailored Treatment Services ......................................................................................

      • Chronic Disease Management ...................................................................................



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

      • Evidence-Based Practices ....................................................................................... The Addiction Treatment Workforce is Not Qualified to Implement

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

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

      • Inadequate Quality Assurance ...................................................................................

      • Inadequate Insurance Coverage .................................................................................





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

    • Mainstream Medicine ................................................................................................... Efforts to Integrate Substance Use Prevention and Treatment into



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