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Position Statement 33: Substance Use, Abuse, or Dependence and Co-Occurring Interactive Disorders

Policy

Mental Health America (MHA) advocates complete integration of substance use and mental health outreach, identification and treatment. Early identification of substance use and mental health disorders should be followed by early treatment, without regard for administrative systems and funding silos. Prevention of disorders and promotion of health and wellness also must be fully integrated to be effective. Co-occurring mental health conditions and substance abuse or dependence are truly "interactive" in that they each may exacerbate one another.

A broad cross section of the population in the United States is affected by substance use disorders and co-occurring interactive disorders. Thus, MHA advocates for comprehensive, integrated, effective, accessible, and culturally and linguistically appropriate wellness, prevention, early identification, treatment, and supportive services for people experiencing substance use and co-occurring interactive disorders and their families and partners. These conditions have a dramatic impact on the lives of individuals, their families and partners, and society as a whole, throughout the lifespan.

MHA and its affiliates will assist whenever possible in developing effective collaboration between stakeholders, advocating mental health and substance use disorder outreach, identification, treatment and supportive services. Housing and treatment providers, consumers, families, and advocacy organizations must integrate their efforts to achieve the systems integration that is so urgently needed. Mental Health America reaffirms its commitment to extend its traditional mental health advocacy to both substance and co-occurring interactive disorders as important elements to be fully integrated into all of its programs, services, and public education. 1

Background

Alcoholism and drug abuse and dependence are recognized as primary, progressive, chronic, relapsing and treatable diseases, with clear diagnostic categories in the American Psychiatric Association' Diagnostic and Statistical Manual-Fourth Edition (DSM) and with extensive evidence-based treatment principles and protocols. About half of people with schizophrenia are likely to have a co-occurring substance use disorder over their lifetime; with bipolar disorder, that likelihood increases substantially. People with major depression and panic disorders are likely to have co-occurring substance use disorders at the rates of nearly 30% and 22% respectively as compared with about 15% in the general population. 2

Prescription drug abuse is an area of growing concern. The National Survey on Drug Use and Health estimated that in 2003, 6.3 million Americans aged 12 and older abused prescription drugs (that is, took medications not prescribed for them or took medications solely for pleasure or entertainment) in the month preceding the survey. Most of the identified survey participants abused pain relievers (4.7 million); others abused tranquilizers (1.8 million), stimulants (1.2 million), and sedatives (0.3 million). 3

The use of illicit drugs among Americans increased dramatically through 2010. The 2010 National Survey on Drug Use and Health showed that 22.6 million Americans 12 or older (8.9 percent of the population ) were current illicit drug users. The rate of use in 2010 was similar to the rate in 2009 (8.7 percent), but remained above the 2008 rate (8 percent).

An increased rate in the current use of marijuana seems to be one of the prime factors in the overall rise in illicit drug use. In 2010, 17.4 million Americans were current users of marijuana - compared to 14.4 million in 2007. This represents an increase in the rate of current marijuana use in the population 12 and older from 5.8 percent in 2007 to 6.9 percent in 2010.

Another disturbing trend is the continuing rise in the rate of current illicit drug use among young adults aged 18 to 25 -- from 19.6 percent in 2008 to 21.2 percent in 2009 and 21.5 percent in 2010. This increase was also driven in large part by a rise in the rate of current marijuana use among this population.

In 2004, the World Health Organization published a report entitled "Neuroscience of Psychoactive Substance Use and Dependence." 4 The Report Summary underscores the following points:

  • There is a need to increase public awareness regarding the complex nature of the problems and the biological processes underlying drug dependence.
  • "...with recent advances in neuroscience, it is clear that substance dependence is a disorder of the brain as any other neurological or psychiatric illness."
  • "Substance dependence is a chronic, relapsing disorder with a biological and genetic basis, and is not simply due to a lack of will or desire to quit."
  • The greatest barrier to integrated treatment is the "silo" mentality - the fragmentation of mental health and substance use treatment services. 5

Substance Use Disorders:

"Substance abuse and substance dependence are two types of substance use disorders and have distinct meanings." 6   Substance dependence is more serious than substance abuse. This maladaptive pattern of substance use includes such features as an increased tolerance for the substance, resulting in the need for ever-greater amounts of the substance to achieve the intended effect; an obsession with securing the substance and with its use; or persistence in using the substance in the face of serious physical or mental health conditions. An additional feature is the cognitive dissonance of persistent desire combined with unsuccessful efforts to cut down or control the substance use. Dr. Kessler, a professor of health care policy at Harvard Medical School, and his colleagues reported in 1996 from the National Co-morbidity Survey that, "all the mental disorders are consistently more strongly related to dependence than abuse." 7 Although the term is used loosely, substance abuse is identified as a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences as a result of the substance use. Substance abuse does not include dependence, tolerance, withdrawal, or a pattern of compulsive use.

Soon after the end of alcohol prohibition in 1933, Alcoholics Anonymous (AA) was born. Formed in 1935 by stockbroker Bill Wilson and a physician, Robert Smith, AA supported the proposition that an alcoholic is unable to control his or her drinking and recovery is possible only with total abstinence and peer support. The chief innovation in the AA philosophy was that it proposed a biological explanation for alcoholism. Alcoholics constituted a special group who are unable to control their drinking from birth. Initially, AA described this as "an allergy to alcohol."

Although AA was instrumental in emphasizing the "disease concept" of alcoholism, the defining work was done by Elvin Jellinek, M.D., of the Yale Center of Alcohol Studies. In his book, The Disease Concept of Alcoholism, published in 1960, 8Jellinek described alcoholics as individuals with tolerance, withdrawal symptoms, and either "loss of control" or "inability to abstain" from alcohol. He asserted that these individuals could not drink in moderation, and, with continued drinking, the disease was progressive and life-threatening. 9

Despite some lingering controversy, most national organizations now have described alcoholism and substance dependence as medical conditions. They include the American Medical Association, the American Psychiatric Association, the American Hospital Association, the American Public Health Association, the National Association of Social Workers, the World Health Organization and the American College of Physicians. 10

Federal agencies have also identified alcoholism and substance dependence and abuse as diseases or illnesses. They include:

Integrated Treatment is Effective:

Twenty-six studies show that integrated treatment for co-occurring mental illnesses and substance use conditions is more effective than traditional separate treatment approaches. 11

Addiction Treatment Is Effective:

Addiction treatment reduces substance use, illegal activity, and suicidal ideation. The outcomes are generally stable for clients at five-year follow-up. 12 The conclusion that treatment is effective is found in over 600 published scientific papers. 13 Relapse rates for treatment of alcohol, opiates, and cocaine are less than those for hypertension and asthma, and equivalent to those of diabetes (all chronic conditions). Compliance rates for treatment of alcohol, opiates, and cocaine are greater than compliance for hypertension and asthma. 14

SAMHSA concluded in 2009: There is a great paucity on nationwide data related to the cost benefit of substance use treatment. However, the limited research in some states suggests that there is a major benefit to substance use treatment. According to recent estimates, the total financial cost of drug use disorders to the United States is estimated to be $180 billion annually. The economic costs of alcohol abuse were $184.6 billion in 1998. The benefits of treatment far outweigh the costs. Even beyond the enormous physical and psychological costs, treatment can save money by diminishing the huge financial consequences imposed on employers and taxpayers. 15

Treatment Capacity is Insufficient:

In 2009, 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (9.3 percent of persons aged 12 or older). Of these, 2.6 million (1.0 percent of persons aged 12 or older and 11.2 percent of those who needed treatment) received treatment at a specialty facility. Thus, 20.9 million persons (8.3 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a specialty substance abuse facility in the past year. 16 The people who could have benefited from treatment but did not receive it continue to suffer ongoing personal problems and consequences in their lives.

The impact to public health and safety is exacerbated by the lack of adequate recovery opportunities provided for those who receive addiction treatment. Between 20-30 percent of patients seen in American hospital emergency departments have alcohol problems. According to the SAMHSA DAWN 2011 report, of the 108 million emergency department visits, 31 percent involved illicit drugs only and 27 percent involved pharmaceuticals only. Over half, 56 percent, of all drug misuse/abuse emergency department visits involved an illicit drug alone or in combination with another drug (with the highest rates involving cocaine and marijuana). 17 It is unknown how many patients have other substance use conditions. 18 However, most emergency departments do not routinely screen for alcohol and other substance use conditions. In older studies, as few as 15 percent of emergency department patients with alcohol problems had their drinking behavior addressed while in the emergency department or through a referral for problem drinking.

Nearly half of alcohol-related deaths are the result of motor vehicle crashes, falls, fires, drowning, homicides, and suicides. 19 Alcohol use is associated with 1/3 of all suicides. 20 There were approximately 79,000 deaths annually for the years from 2001–2005 that were attributable to excessive alcohol use, mostly from alcohol-related traffic accidents. 21 708,000 persons are injured in alcohol related car crashes every year, and 74,000 of those suffer serious injuries. 22 The burden of untreated alcohol abuse and dependency is enormous.

Addiction and Homelessness:

Approximately 70 percent of participants in a 2005 National Institute on Alcohol Abuse and Alcoholism (NIAAA) demonstration project identified substance abuse problems as the primary reason for their homelessness in both the first and most recent episodes. Among those in shelters, 86 percent are estimated to have alcohol problems, and 60 percent have problems with illicit drugs. 23

Early Alcohol and Drug Use:

Fetal Alcohol Spectrum Disorder (FASD) refers to a range of effects that can occur to a person whose mother consumed alcohol during pregnancy (e.g. physical, mental, behavioral, and/or learning disabilities). FASD is also associated with a range of secondary problems that include depression, psychotic episodes, anxiety disorders, eating disorders, posttraumatic stress disorder, and alcohol or drug problems. An estimated one third of people with FASD have had alcohol or drug problems, with more than half requiring inpatient treatment. 24

Adolescence is the transition between childhood and adulthood. During this time, significant changes occur in the body, including rapid hormone alterations and the formation of new networks in the brain. A psychoactive drug produces an intoxicating effect by acting on one or more chemical messenger systems in a person's brain. Early alcohol use may have lasting consequences. People who begin drinking before age fifteen are four times more likely to develop alcohol dependence at some time in their lives compared to those who have their first drink at age twenty or older. 25 Early use of marijuana showed substantial effects on later incidence of alcohol dependence, substance use conditions, and major depressive disorder in a NIDA funded longitudinal study of more than 700 individuals from early childhood into their late twenties. 26 A 2011 meta-analysis provides evidence for a relationship between cannabis use and earlier onset of psychotic illness, and they support the hypothesis that cannabis use plays a causal role in the development of psychosis in some patients. 27

Co-Occurring Disorders:

The best estimate of the prevalence of co-occurring substance dependence or abuse and mental health conditions is contained in the combined data from the Epidemiologic Catchment Area (ECA) Survey and the National Comorbidity Survey (NCS) 28 Based on these studies, up to 10 million persons in the United States have co-occurring mental health and substance use conditions in any given year. If not treated early and effectively, these conditions "may become chronic; may lead to other disorders; may increase symptoms by interacting with each other; may cause disability; and are likely to increase the cost of care." 29 The NCS indicates that 3 million persons who are experiencing co-occurring disorders are affected by at least three disorders and 1 million individuals are affected by four or more disorders: "As the number of disorders increases, the likelihood of serious persistent mental illness, disability, and heavy use of health and social services also increase." 30 The most common cause of psychiatric relapse today (in the dually diagnosed population) is the use of alcohol, marijuana, and cocaine. The most common cause of relapse to substance dependency/abuse is untreated psychiatric disorder.

Both substance use and mental health conditions have biological, psychological, and social components. Part of the difficulty in treating these conditions when they co-occur is that they affect the same part of the body -- the brain -- a factor that complicates treatment, including the use of medications.

Treatment programs, peer support programs, and self-help organizations (Including Alcoholics Anonymous, Narcotics Anonymous, Dual Recovery Anonymous, Methadone Anonymous, SMART Recovery, Inc. and Women for Sobriety) provide an array of recovery supports. It is important to understand the roles and boundaries of programs and organizations. William White's seminal work, Slaying the Dragon: The History of Addiction Treatment and Recovery in America, 31 is an important resource to gain an understanding of addiction treatments, peer support programs, and self-help organizations.

Call to Action

Mental Health America encourages its affiliates and other mental health and substance dependence/abuse service stakeholders to advocate for mental health and substance use service systems that are recovery and wellness oriented, family and partner supportive, consumer driven, integrated, comprehensive, and culturally and linguistically competent, by:

  • Advocating for the involvement of consumers of mental health and substance dependence/abuse services in the planning, implementation and evaluation of early identification and intervention, treatment, and recovery support services for mental health conditions, substance dependence/abuse conditions, and co-occurring interactive disorders.
  • Advocating for integration of mental health and substance dependence/abuse recovery and general health services for persons experiencing co-occurring interactive disorders regardless of service delivery setting.
  • Initiating community based coalitions to address the availability and accessibility of treatment and recovery services for substance dependence/abuse and co-occurring interactive disorders. In addition, recognizing and addressing the need for early detection and intervention programs.
  • Building and developing core curricula, including appropriate training and experience in mental health and substance use.
  • Educating the public about substance dependence/abuse and co-occurring disorders in order to mitigate stigma and prejudice that limit appropriate services.
  • Advocating for faithful implementation and enforcement of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. 32
  • Monitoring outcomes of diversion for substance-related offenses.

Effective Period:

This policy was approved by the Mental Health America Board of Directors on June 9, 2012. It is reviewed as required by the MHA Public Policy Committee.

Expiration: December 31, 2017

  1. Drake, R.E., Mueser, K.T., Brunette, M.R., & McHugo, G.J., “A Review of Treatments For People With Severe Mental Illnesses and Co-Occurring Substance Use Disorders,” Psychiatric Rehabilitation Journal 27(4):360-374 (2004).
  2. Kessler, R.C., Nelson, C.B., McGonagle, K.A., Edlund, M.J. Frank, R.G. & Leaf, P.J., “The Epidemiology of Co-occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization,” American Journal of Orthopsychiatry 66(1):17-31 (1996).
  3. United States Department of Health and Human Services, Office of Applied Studies, Results from the 2004 National Survey on Drug Use and Health: National Findings (DHHS Publication No. SMA 05-4062, NSDUH Series H-28). Rockville, MD: Substance Abuse and Mental Health Services Administration (2005). 2010 update: http://www.samhsa.gov/newsroom/advisories/1109075503.aspx
  4. http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf
  5. New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America/Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003, monograph available for download at http://store.samhsa.gov/product/Achieving-the-Promise-Transforming-Menta...
  6. Substance Abuse Treatment for Persons with Co-Occurring Disorders (TIP 42), United States Substance Abuse and Mental Health Services Administration, Rockville, MD (2005), monograph available at http://www.breining.edu/TIP42CoOccDis.pdf Inservice Training manual available at: http://www.kap.samhsa.gov/products/trainingcurriculums/pdfs/tip42_curric...
  7. Kessler, R.C., Nelson, C.B., McGonagle, K.A., Edlund, M.J., Frank, R.G. & Leaf, P.J., “The Epidemiology of Co-occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization,” American Journal of Orthopsychiatry 66(1):17-31 (1996).
  8. Alcohol Research Documentation; Later Printing edition (1960)
  9. Page, P.B., "E. M. Jellinek and the Evolution of Alcohol Studies: A Critical Essay," Addiction 92(12):1619-1637 (1997)
  10. Hobbs, Thomas R., PhD, MD., for the Pennsylvania Medical Society, "Managing Alcoholism as a Disease." Physicians News Digest, http://www.physiciansnews.com/commentary/298wp.html (February 1998). Additional organizations that use the terminology of "disease or illness” include: the National Association of State Alcohol and Drug Abuse Directors http://www.nasadad.org/, "Join Together," a program of Boston University http://www.jointogether.org/, the National Association of Alcohol and Drug Abuse Counselors http://www.naadac.org/, Faces and Voices of Recoveryhttp://www.facesandvoicesofrecovery.org/, and the National Council on Alcoholism and Drug Dependence http://www.ncadd.org/.
  11. Drake, R.E., Mueser, K.T., Brunette, M.F., & McHugo, G.J. (2004), op. cit.; Hubbard, R.L., “Overview of 1-Year Follow Up Outcomes on Drug Abuse Treatment Outcome Study (DATOS),” Psychology of Addictive Behavior 11:261-278 (1997); Hubbard, R. L., Craddock, S. G., & Anderson, J., “Overview of 5-year Follow-up Outcomes in the Drug Abuse Treatment Outcome Studies (DATOS), Journal of Substance Abuse Treatment, 25(3):125-134 (2003).
  12. Id.
  13. O’Brien, C.P. & McLellan, A.T., “Myths about the Treatment of Addiction,” The Lancet 347: 237-240 (1996).
  14. Id.
  15. http://www.samhsa.gov/grants/CSAT-GPRA/general/SAIS_GPRA_CostOffsetSubst...
  16. http://www.samhsa.gov/data/2k9/2k9Resultsweb/web/2k9results.htm#1.1
  17. Substance Abuse and Mental Health Services Administration (SAMSHA), Office of Applied Studies, Drug Abuse Warning Network, 2005: National Estimates of Drug-Related Emergency Department Visits." DAWN series D-29, DHHS, Rockville, MD (2007). Substance Abuse and Mental Health Services Administration (SAMSHA), Center for Behavioral Health Statistics and Quality, Drug Abuse Warning Network, 2009: National Estimates of Drug-Related Emergency Department Visits." DAWN series D-35, DHHS, Rockville, MD (2011), monograph available at http://www.samhsa.gov/data/2k11/DAWN/2k9DAWNED/HTML/DAWN2k9ED.htm.
  18. Studies have shown prevalence rates for positive toxicology (excluding alcohol) ranging from 20% to 45%. Cherpitel, C. J. & Guilherme, Borges, "Substance Use Among Emergency Room Patients: An Exploratory Analysis by Ethnicity and Acculturation." American Journal of Drug and Alcohol Abuse 28(2):287-305 (2002), available at: http://www.mendeley.com/research/substance-among-emergency-room-patients...
  19. Lowenstein, S.R., Weissberg, M.P. & Terry, D., "Alcohol Intoxication, Injuries, and Dangerous Behaviors -- and the Revolving Emergency Department Door," J Trauma 30(10):1252-8 (1990).
  20. Cherpitel, C.J., Soghikian, K. & Hurley, L.B., “Alcohol-related Health Services Use and Identification of Patients in the Emergency Department, Ann Emerg Med 28(4):418-23 (1996).
  21. National Center for Injury Prevention and Control, CDC Injury Fact Book, Atlanta (GA): Centers for Disease Control and Prevention (2006), available at http://www.cdc.gov/Injury/publications/FactBook/Directors_Messages-2006-...
  22. Id; Ray, O. & Ksir, C., republished (2010) as Hart, C.E. and Ksir, C., Drugs, Society, and Human Behavior.
  23. Alcohol Use Disorders in Homeless Populations, DHHS, Rockville, MD (2005), monograph (Module 10D) available at http://pubs.niaaa.nih.gov/publications/Social/Module10DHomeless/Module10...
  24. Fetal Alcohol Spectrum Disorders:
    Understanding the Effects of Prenatal Alcohol Exposure, NIAAA Alcohol Alert No. 82 (2010).
  25. Id.
  26. Schlabige, J., "Early Use of Drugs May Lead to Later Psychiatric Disorders,” NIDA Notes, Vol.18, No. 5 (2003).
  27. Large, M., Sharma, S., Compton, M.T., Slade, T. & Nielssen, O., “Cannabis Use and Earlier Onset of Psychosis,” Arch Gen Psychiatry 68(6):555-561 (2011). doi:10.1001/archgenpsychiatry.2011.5 http://archpsyc.ama-assn.org/cgi/content/abstract/68/6/555
  28. Improving Services for Individuals at Risk of, or with, Co-Occurring Substance-Related and Mental Health Disorders, A Report of the National Advisory Council, United States Substance Abuse and Mental Health Services Administration, Rockville, MD (1997), no URL found.
  29. Id.
  30. Id.
  31. (Chestnut Health Systems, Bloomington, IL 1998)
  32. PL 110-343

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