Alcohol, Drugs, and Health: Highlights from The Surgeon General’s Report
Tom Horvath, Ph.D., and Thaddeus Camlin, Psy.D.
Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, released in November, has received considerable attention. The massive effort involved in creating this document is in itself worthy of respect. The opening pages list seven science editors, three managing editors, five contributing editors, 21 contributing authors, one science writer, 117 reviewers, and 10 other contributors (these individuals apparently being mostly involved in production). The professionals involved include many of the most important individuals in the fields of addiction and recovery.
You may have heard the expression that a camel is a horse that was designed by committee. The implication being that when too many people get involved a great design can get altered for the worse. Nevertheless, it appears this document has gained from its inclusiveness.
The Report is 413 pages, has thousands of references, and includes seven sections:
- Introduction And Overview Of The Report
- The Neurobiology Of Substance Use, Misuse, And Addiction
- Prevention Programs And Policies
- Early Intervention, Treatment, And Management Of Substance Use Disorders
- Recovery: The Many Paths To Wellness
- Health Care Systems And Substance Use Disorders
- Vision For The Future: A Public Health Approach
Each section begins with text box summary, making a review of the Report straightforward. It is available for free download here.
Not surprisingly the Report indicates that severe substance use disorder is a chronic brain disease. An entire section (#2) is devoted to describing the data behind this assertion. The first statement in the textbox summary of section 2 is: “Well-supported scientific evidence shows that addiction to alcohol or drugs is a chronic brain disease that has potential for recurrence and recovery. “ However, the Report talks about substance misuse about eight times as often as it does brain disease (163 pages vs. 21 pages). Furthermore, there seems to be no suggestion that someone can “have the disease” prior to manifesting severe substance use disorder. The disease develops with long-term substance use, and does not exist in advance of that use. Then, as is typical for this perspective, the rest of the report focuses on the latest findings and recommendations in each area, with little further integration of the idea that addiction is a disease.
Why are we pleased with this Report? Consider the following excerpts.
In some recovery circles the term harm-reduction is almost synonymous with insanity. The Report is a big step towards de-stigmatizing and adding credibility to effective, evidenced-based harm–reduction approaches. There is a “treatment gap” (p.4-8) such that “only…about 1 in 10 affected individuals, received any type of treatment in the year before” (p. 4-8). The most common reason for not seeking treatment is “not ready to stop using” (p. 4-9). Consequently, harm reduction is needed.
Specific harm-reduction strategies mentioned include needle-exchange programs and medication-assisted treatment (MAT): “Needle/syringe exchange programs are effective in reducing HIV transmission and do not increase rates of community drug use” (p. 4-11).
Medication-assisted treatment is promoted because of its “well-supported experimental evidence of safety and effectiveness” (p. 4-21):
Studies have repeatedly demonstrated the efficacy of MAT at reducing illicit drug use and overdose deaths, improving retention in treatment, and reducing HIV transmission. Some medications used to treat opioid use disorders can be used to manage withdrawal and as maintenance treatment to reduce craving, lessen withdrawal symptoms, and maintain recovery. These medications are used to help a patient function comfortably without illicit opioids or alcohol while balance is gradually restored to the brain circuits that have been altered by prolonged substance use (p. 4-21).
Despite the encouraging empirical data, several factors impede widespread implementation of MAT:
Multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation (p. 4-21).
Comorbidity and a Holistic Approach
The report discusses the frequency of traumatic experiences with people who have substance use problems, highlighting:
The high prevalence of co-existing alcohol use disorder in those meeting criteria for PTSD. It is estimated that 30-60 percent of patients seeking treatment for alcohol use disorder meet criteria for PTSD, and approximately one third of individuals who have experienced PTSD have also experienced alcohol dependence at some point in their lives (pp. 2-22-23).
Substance problems need to be viewed in the individual’s full life context:
The experiences a person has early in childhood and in adolescence set the stage for future substance use and sometimes escalation to substance use disorder or addiction. Early life stressors can include physical, emotional, and sexual abuse; neglect; household instability (such as parental substance use and conflict, mental illness, or incarceration of household members); and poverty. Research suggests that the stress caused by these risk factors may act on the same stress circuits in the brain as addictive substances, which may explain why they increase addiction risk (p. 2-21).
There are major problems with confrontation:
Planned surprise confrontations —a model developed in the 1960s, sometimes called the “Johnson Intervention”—have not been demonstrated to be an effective way to engage people in treatment. Confrontational approaches in general, though once the norm even in many behavioral treatment settings, have not been found effective and may backfire by heightening resistance and diminishing self-esteem on the part of the targeted individual (p.1-18).
Personalized care, not “programs,” is needed:
Personalized care is not common in the substance use disorder field because many prevention, treatment, and recovery regimens were created as standardized “programs” rather than individualized protocols (p. 1-24).
(Practical Recovery is proud to state that we have offered personalized care for over 30 years.)
Continued reason for optimism about recovery
Remission of substance use and even full recovery can now be achieved if evidence- based care is provided for adequate periods of time, by properly trained health care professionals, and augmented by supportive monitoring, RSS, and social services. This fact is supported by a national survey showing that there are more than 25 million individuals who once had a problem with alcohol or drugs who no longer do (p.1-19).
Stanton Peele’s critique of this Report is well worth reading, and we fundamentally agree with it. Nevertheless, the Report appears to be a major advance because it is not so far ahead of the field as a whole as to be impractical. The Report sets standards that we could begin to expect adherence to now. Let’s see if that adherence occurs.