Combined Alcohol and Drug Abuse Problems. Edward Gottheil, Section Editor

Transcription

1 Combined Alcohol and Drug Abuse Problems I Edward Gottheil, Section Editor

2 Overview Edward Gottheil Although people have been using and abusing many substances for many centuries, the field of addiction is relatively new. It probably had its origins in the 1940s when it gained public and scientific attention mainly through the efforts of Alcoholics Anonymous and the National Council on Alcoholism. There was further recognition in the 1950s, with acceptance by the American Medical Association and inclusion in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. It was firmly established with the creation of the National Institute on Alcohol Abuse and Alcoholism (NJAAA). Prior to the 1960s, the field was not very complicated. To be sure, there was much to be learned, but the main research and clinical problems, by far, were those relating to alcoholism. The field expanded markedly with the drug abuse epidemic of the 1960s and the establishment of the National Institute on Drug Abuse (NIDA). Currently, the field may be undergoing another expansion with the emergence of cocaine use and abuse and becoming more complicated with the steadily increasing numbers of polydrug abusers. Since the field is as young as it is and there are so many gaps in our knowledge regarding the epidemiology, etiology, pharmacology, diagnosis, and treatment of alcoholism and narcotic addiction, to say nothing of cocaine abuse and the many other substance abuse disorders, it is not surprisjng that research and clinical programs have tended to focus either on alcoholism or on drug abuse and to avoid studying and treating combined disorders. Indeed, there are still many problems regarding definition and classification and whether there should be a unified field of addiction. We thought it would be worthwhile, therefore, to bring together reviews of what was known about the epidemiology, interactive mechanisms, pharmacologic management, and psychosocial treatment of combined substance use disorders. Any attempt to study the prevalence of polydrug use must begin by specifying what is to be counted. What constitutes abuse and what qualifies as combined or multiple abuse? In the case of illicit drugs, any use may be considered abuse even though we know that some individuals are able to Edward Gottheil Department of Psychiatry and Human Behavior, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania M. Galanter et al. (eds.), Recent Developments in Alcoholism Springer Science+Business Media New York

3 4 I Combined Alcohol and Drug Abuse Problems use some of these drugs recreationally without any escalation of use and without any apparent adverse consequences. If occasional use of marijuana is not to be counted, or if DSM III criteria for abuse are to be employed, this must be explicitly stated. For licit drugs such as alcohol, tobacco, or prescribed substances, it is clear that abuse must be defined and distinguished from use. It is also necesssary to indicate whether abuse of one substance along with use, but not abuse, of other substances is to be included or excluded; i.e., do we count an alcoholic who smokes one package of cigarettes per day and occasionally uses marijuana and cocaine in social situations? Moreover, should we include multiple sequential users as well as multiple concurrent users, i.e., does an individual who sniffed glue as a child, was an amphetamine abuser during his teens, and who recently began taking heroin qualify? Once the data are collected and tabulated, the next issue is how to classify the possible combinations. There are 362,880 combinations of ten drugs taken two at a time. The possibilities increase markedly if we consider more than ten drugs which may also be taken three, four, or five at a time; and we have not yet considered the amount ingested of each drug in the combination, the frequency of use, and the route of administration. In Chapter 1 Clayton discusses such issues and critically reviews the various ways that have been used to describe patterns of multiple drug use: developmental patterns of onset, drug clusters, typologies of drug users, and the construction of composite indices intended to reflect the seriousness of drug use. Clayton then goes on to examine the information available in several national data sets to ascertain the extent of multiple drug use and comes to the straightforward conclusion that multiple drug use is pervasive. In view of this reality, he suggests we rethink some of our ideas and reexamine some of our studies that almost automatically attribute automobile accidents to alcohol and overdose deaths to heroin and that we inquire whether and to what extent specific combinations of multiple drugs may playa role in the occurrence of these adverse consequences. Similarly, he discusses policy issues relevant to prevention and treatment that may require reevaluation. For example, current concerns about health care costs are resulting in policies that focus on lengths of stay for specific treatments of specific conditions, while, at the same time, the increasing prevalence of multiple drug use is resulting in patients entering treatment who often do not come in the sizes and shapes that fit the particular slots specified by our treatment system. Multiple drugs may be used for enhancement (e.g., alcohol and valium) or counteraction (e.g., cocaine and heroin). These interactions, or at least some of them, have been learned on the "street" and are not new to the pharmacologist. However, the number of studies needing to be done to determine the effects of so many different combinations of drugs that vary in their acute and chronic patterns of use and in their dosage, frequency, and route of administration is staggering. Schoerner in Chapter 2 notes that when we take into account the dynamic and kinetic processes of the individual drugs, as well as their interactions in combinations, and also factor in the

4 I Overview 5 different time frames and drug use histories that occur in real life, we are faced with a situation of virtually infinite complexity because of the everchanging bloodlbrain levels of free drug and the functional tolerance and dependence that are engendered to varying degrees over time. He emphasizes the need for subjecting these interactions to sophisticated multivariate analyses, which at present are only in their infancy. Nevertheless, much is known about the basic principles of drug interactions. Schoerner illustrates these principles with respect to the depressant group of drugs. He reviews the pharmacodynamic and pharmacokinetic properties of ethanol, the benzodiazepines, and the sedative hypnotics and discusses the various types of mechanisms involved in their depressant actions and interactions. Cushman (Chapter 3) also comments about the increasing use of combinations of drugs and the gaps in our knowledge about interactions among them. He gives examples that emphasize the importance of recognition and diagnosis for the appropriate medical management of these conditions. The acute and chronic actions of these drugs, alone and in combination, are reviewed in relation to the development of appropriate principles of treatment. Throughout the chapter, practical issues related to clinical management are considered, such as the effects of adulterants when street drugs have been used, indications for inpatient detoxification, and the special problems for the anesthesiologist of tolerance and cross-tolerance. In the final chapter of this section, Carroll (Chapter 4) contends that to continue to maintain the current segregation of alcohol dependence and drug dependence programs in the face of mounting clinical and scientific evidence of the preeminence of multiple substance abuse makes no sense. It may lead to inadequate diagnoses, a failure to admit many cases with multiple substance abuse, incomplete treatment, a lack of understanding of the epidemiology of substance abuse, and, worst of all, relapse to addiction subsequent to treatment. He proposes the adoption of a II generic" perspective of addictions or substance abuse problems, according to which the choice of a particular substance and its particular manifestations is less important than the fact that one is abusing some substance capable of leading to dependence and addiction. Although there are differences that are important for detoxification and medical management, the etiology, defenses, dynamics, and therapeutic principles are seen as essentially similar regardless of the substance or substances abused. From this perspective, varieties of combined treatment methodologies are described in detail, as well as implications for staffing and training. It seems apparent that multiple substance abuse is a real and pervasive public, clinical, and scientific problem. As a research area it should be extremely attractive to investigators of many disciplines. It is an important problem; there is a need to know; and the area is not uncharted. Many of the principles and techniques are available and gaps in our knowledge are clearly identified. Yet, there are effective barriers to such research resulting

5 6 I Combined Alcohol and Drug Abuse Problems from the segregation of our alcohol and drug research and treatment institutions. Earlier in this century, the psychoanalysts searching for broad psychodynamic explanations of behavior were impressed by the many similarities they found in the histories of alcoholics and drug addicts. Together with smokers, gamblers, and the obese, they were seen as deriving from difficulties encountered during the oral stage of psychosexual development and considered as varieties of impulse disorders. In recent decades, however, alcoholism and drug addiction reappeared as separate entities. NIAAA was established in response to the pressure of Alcoholics Anonymous and the National Council on Alcoholism, and, later, NIDA was created almost overnight in response to the drug abuse epidemic of the 1960s. Representing different constituencies, their research and treatment programs, not surprisingly, were not integrated but underwent separate developments with little overlap. While the psychoanalysts had emphasized similarities among individuals, the programs funded by separate institutes emphasized differences between substances. Although there are notable exceptions, by and large, NIAAA funds research on alcoholism and NIDA funds research on drug abuse; the alcoholic goes to an alcoholism treatment program, and the drug abuser goes to a drug abuse treatment program. Where, then, is the researcher interested in studying combined alcohol and drug abuse problems to go for funds or subjects? The institutionalized separation of alcoholism and drug addiction has become ingrained in our thought and language patterns. It seems perfectly natural to talk about alcohol and drug abuse even though alcohol is a drug. We would not talk about cows and animals, since the class of animals includes cows. We would refer to cows and other animals. Interestingly, to our programmed ears, alcohol and other drug abuse sounds stilted though correct, and we prefer alcohol and drug abuse though incorrect. There has been some movement toward reintegration. Combined alcohol and other drug abuse research, prevention, teaching, and clinical programs have been developed and have been funded. Journals and national societies are reflecting this movement. Yet, much remains to be done and much remains to be learned about combined or multiple substance abuse. In the meantime, whether our researchers, administrators, and program planners are ready or not, our clinicians are continuing to see steadily increasing numbers of polydrug abusers.