Preface

Substance use disorders are among the most compromising problems that confront health professionals. In the United States, 18% of people experience a substance use disorder at some point in their lives, and some 20% of patients in general medical facilities and 35% in general psychiatric units present with substance use disorders. Although the sequelae of addiction, such as cirrhosis, psychopathology, trauma, and infection, generally receive proper medical attention, patients' primary addictive problems often go untreated.

Public and governmental awareness of the need for greater research and treatment resources has, however, increased in recent years, and substance abusers now seek help earlier, at a point when treatment can be administered more effectively. Additionally, health care providers have been well-alerted to the need for early diagnosis and comprehensive care, and new treatment concepts, both pharmacological and psychosocial, have made a recovery process a possibility for most alcohol and drug-abusing patients. The longstanding struggle to assure parity for treatment of substance use disorders with other medical illnesses therefore takes place in a society increasingly cognizant of the medical and humanitarian benefit of pursuing this goal.

We are heartened by the important advances made in the underlying science, the technology of psychosocial modalities, and the growth of pharmacotherapies in our field. At the same time, however, one very important issue must be implicit in the clinician's work: one's opportunity to help substance abusers overcome their illnesses still rests on the ability to relate to each given patient. The defensiveness and denial characteristic of the disorders we examine in this book can only be overcome by an intuitive and empathic engagement with their suffering and a willingness to stay with the patient through the vicissitudes of recovery. We hope that this volume enables the reader to gain the knowledge necessary to apply this important skill.

Substance abuse is a major problem both nationally and internationally. Drug trends tend to rise, peak, fade, and then re-emerge. Methylenedioxymethamphetamine (MDMA; “ecstasy”) rose sharply in the 1990s, dropped dramatically in the early years of the current decade, and is now on the rise again. Heroin use increased during the 1990s and has lately been stable, but prescription opioid abuse has sharply increased. Part of the shifting trends relate to generational forgetting (e.g., in the case of ecstasy); others relate to increased purity and decreased price (e.g., heroin) or changes in availability secondary to prescribing patterns (e.g., prescription opioids and stimulants).

Drug use patterns observed in the United States also appear in other countries. Australia and Canada, for example, now have similar patterns of static or decreased heroin use and increased prescription opioids. Numerous countries, especially in Asia, are experiencing sharp increases in the use of amphetamine-type stimulants. Regardless of the trend, we unfortunately can be certain that substance use and abuse will remain major public health problems for the foreseeable future. This has led to the formation of several organizations overseas established to address the addiction problem. One such group that seeks to bring together researchers and clinicians is the International Society of Addiction Medicine, with a large complement of members in countries throughtout the six continents, including a sizeable American membership, and with ties to the National Institute on Drug Abuse in the United States.

The first edition of this volume emerged from the growing commitment of the country to address the problem of substance abuse. In the decades before the first edition came out, a number of significant events occurred, including the establishment of National Institutes on both alcohol and drug abuse in the early 1970s. In 1982, the American Psychiatric Association established its Task Force on Treatment of Psychiatric Disorders, consisting of 26 panels. We served as chairpersons of the panels on disorders of alcohol and other drug abuse, respectively. In response to this APA initiative, we brought together a group of experts who could provide a carefully drawn perspective on addiction treatment, perhaps the most comprehensive one to date.

Soon after the publication of the Task Force's volumes, we decided that it was important to update and amplify the substance abuse treatment information. We wanted to focus on the most recent developments in biological and psychosocial therapies and the problems of specific populations.The resulting volume, the first edition of this textbook, was published in 1994. The second followed in 1999, and the third in 2004. We are now pleased to present a fully updated version of this textbook, tailored to present the most current basic science and clinical information on the substance abuse field. In accordance with the need to provide fresh perspectives on the issues presented, new chapters have been added and new authors have been invited to present the issues covered. For example, because of a growth in the basic understanding of mechanisms of action of different drugs of abuse, we are now presenting separate chapters on the biology and clinical management for each of the drug categories in the second section of this book. The nature and role of buprenorphine, an important addition to the armamentarium of physicians treating opioid addiction, is now presented in much greater detail. A greater understanding of the nature of 12-step programs and their role in addiction treatment has allowed for more attention to this fellowship. In order to increase the utility of this volume, we have made more use of tabular presentation of material.

Substance abuse training is now an integral part of undergraduate curricula in most medical schools and is allocated a one-month, full-time equivalent component in psychiatry residency programs. The approval of the American Board of Psychiatry and Neurology (ABPN) for an Added Qualification in Addiction Psychiatry was of major importance in establishing addiction as a medical subspecialty. The American Board of Medical Specialties, under its guidelines for establishing subspecialties, sanctioned this process. Certification is given by APBN on the basis of an examination, first given in 1993. A minimum of 1 year of associated training in an accredited PGY5 residency is now required as well. The Accreditation Council for Graduate Medical Education reviews the curricula of these respective training programs, and completion of such a program is required by candidates to sit for the subspecialty examination.

More than 1,800 psychiatrists have been certified in addiction psychiatry. These subspecialists meet a variety of clinical and academic needs, and the range of training experiences provided by the addiction residency programs has been designed to prepare them for this. Postresidency fellowships in addiction psychiatry now number more than 40. Addiction fellows spend about half their time on patient care and devote the rest of their time to research, teaching, and their own learning. These programs have shown considerable vitality and are playing an influential role in ensuring quality treatment for the future. Unfortunately, however, less than half of the population in need of substance abuse treatment actually receives it. This is a function of both the reluctance of private and public payors to adequately fund treatment and the affected population to seek it. More needs to be done on this latter issue.

We have designed this volume to serve clinicians in practice and researchers as well as trainees in psychiatry who are concerned with addiction, general medicine, and other health professions. We hope that this book will serve as a valuable treatment resource for any health care professional concerned with the problems posed by patients with substance use disorders.

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Drs. Kathleen Brady, Henry Kranzler, Edward Nunes, and Bruce Rounsaville had agreed to serve as an editorial board for questions that might arise when we reviewed the chapter manuscripts. We would like to express our appreciation to them for their willingness to be available for consultation.


Marc Galanter, M.D.
Herbert D. Kleber, M.D.