Addiction Medicine: Closing the Gap between Science and Practice

and cutting-edge interventions, the reigning
paradigm in the health community for
addressing risky substance use and addiction is
to fail to address the problem directly. Instead,
risky users of addictive substances are in most
cases sanctioned in terms of the consequences
that result--such as accidents, crimes, domestic
violence, child neglect or abuse--while effective
interventions to reduce risky use rarely are
provided. Those with addiction frequently are
referred to support services, often provided by
similarly-diagnosed peers who struggle with
limited resources and no medical training, to
assist them in abstaining from using addictive
substances. While social support approaches are
helpful and even lifesaving to many--and can be
important supplements to medically-supervised,
evidence-based interventions--they do not
qualify as treatment for a medical disease.

In short, the gap between the evidence regarding
what works in interventions for risky substance
use and in the treatment and management of
addiction versus on-the-ground practice is wide,
and nothing short of a significant overhaul in
current approaches is required to bring practice
in line with the evidence and with the standard
of care for other public health and medical
conditions.

While a wide range of trained health
professionals can screen for risky use of
addictive substances and provide brief
interventions, physicians should be essential
providers of the full range of addiction treatment
services. They should provide this care in
collaboration with multiple medical specialties
and sub-specialties and a multi-disciplinary team
of health professionals, including physician
assistants, nurses and nurse practitioners and
graduate-level clinical mental health
professionals (psychologists, social workers,
counselors).

Given the prevalence of addiction in society and
the extensive evidence regarding how to
identify, intervene and treat it, continued failure
to do so signals widespread system failure in
health care service delivery, financing,
professional education and quality assurance. It
also raises the question of whether the low levels

of care that addiction patients usually do receive

constitutes a form of medical malpractice.

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

Despite the documented benefits of screening

and early intervention practices,* medical and

other health professionals’ considerable

potential to influence patients’ substance use

decisions, and the long list of professional health

organizations that endorse the use of such

activities, most health professionals do not

educate their patients about the dangers of risky

substance use or the disease of addiction, screen

for risky substance use, conduct brief

interventions when indicated, treat the condition

or refer their patients to specialty care if

needed.^2

Since the 1950s, screening has been considered

an important element of general health care and

as early as 1968, the World Health Organization

(WHO) laid out the principles of early disease

detection.^3 Based on those principles, risky

substance use and signs of addiction are highly

conducive to screening by general health

practitioners: they are significant health

problems with well-understood natural histories,

there are non-invasive tests and easily-detected

symptoms and early interventions result in

favorable outcomes.^4 Unfortunately, there is a

considerable gap between what current science

suggests constitutes risky substance use and the

thresholds set in some of the most common

screening instruments for determining that an

individual meets criteria for risky substance use

and is in need of intervention (see Chapter IV).

Medical and other health professionals are in

ideal positions to educate patients, conduct

screening and brief interventions and refer

patients to treatment. The vast majority of

adults (82.2 percent) and children (92.1 percent)

had regular contact with a health professional in

2010.^5 There are many venues where health
professionals can conduct patient education,
screening and brief interventions with relative
ease and most patients would be receptive to

* See Chapter IV.