Fink: Still at Large; Challenges in Treating Substance Abuse. (Opinion)

By Fink, Paul J. | Clinical Psychiatry News, March 2002 | Go to article overview

Fink: Still at Large; Challenges in Treating Substance Abuse. (Opinion)


Fink, Paul J., Clinical Psychiatry News


Data from the latest National Household Survey on Drug Abuse suggest that even though rates of substance use were generally level or declining between 1999 and 2000, use and abuse of licit and illicit substances in the United States remain a major problem.

What challenges have you encountered in providing substance abuse treatment? Have these challenges affected your willingness to work with substance abuse patients?

Readers Respond:

"We live in a society that encourages chemical solutions to life's problems while it blames those who fall prey to addiction to these same substances--whether legal, prescribed, or illicit, " said Dr. Sheila B. Blume, a psychiatrist at the State University of New York at Stony Brook. Dr. Blume's observation echoes the concerns of many psychiatrists, who are challenged to treat substance abuse with increasingly inadequate resources.

According to Dr. Marc Galanter of New York University Medical Center in New York City, approaches to addiction treatment and rehabilitation have improved significantly since the early 1970s, "but this cannot fully make up for the lack of economic support for treatment." Dr. Richard J. Frances, president of Silver Hill Hospital, New Canaan, Conn., said that a lack of adequate public support for allocating resources to addiction treatment is a contributing factor. Only six states include reimbursement for substance abuse treatment in their mental health parity laws.

Several of our readers applauded the Bush administration's effort last month to bridge the gap between those who need treatment and those who already receive it. The administration proposed $127 million in increased funding to the Substance Abuse and Mental Health Services Administration for fiscal year 2003. One very important way to reduce the gap is through the medication buprenorphine, soon to be approved by the U.S. Food and Drug Administration, Dr. Galanter said. Heroin-addicted patients who do not want to be treated with methadone in a clinic would be able to seek alternative treatment in a doctor's office. He also noted that the Substance Abuse Block Grant would receive $60 million of the increase proposed by the Bush administration, some of which should be allocated to train more psychiatrists in addiction treatment.

By far one of the biggest challenges physicians say they face is assisting patients with dual diagnoses. If an insurance provider covers more treatment for the psychiatric diagnosis than the substance abuse diagnosis, patients often are treated primarily for their psychiatric diagnosis, while the substance abuse diagnosis takes a back seat, said Dr. Blume.

Despite the barriers, the psychiatrists who responded to this month's question praise the field for its attention to improving understanding of the physiologic mechanisms of alcoholism, the psychopharmacology of treatment, as well as psychosocial rehabilitation methods. Better dissemination of scientific information to clinical services, however, still needs to be addressed, said Dr. Frances. This responsibility needs to be shared by government organizations, residency training programs, and the media. Physicians also should work harder to communicate with each other.

Dr. Fink Responds:

Specialists in addiction psychiatry are specifically trained to understand and treat patients with substance abuse. Some of them have made cogent statements in response to this month's question. But the problem is that there are too few specialists and many more general psychiatrists across America with far less skill and training who see hundreds of dual-diagnosis and substance abuse patients.

The care of these patients is much more difficult than treating patients with other psychiatric diagnoses. The key mechanism of defense in substance abusers is denial. …

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