Missing the mark on addiction

When treating addiction, contributing mental health issues must be considered. Serious drug problems, and we’re seeing only half of it.

We continue the fight with prescription opioid addiction. Police say that heroin is now undercutting the price of prescription drugs. Intravenous overdose deaths quadrupled between 2011 and 2012, while orally administered prescription opioids – chillingly known as “painkillers” – are responsible for three-quarters of the fatalities. Total drug overdoses have surpassed automobile accidents as the leading cause of accidental death.

And that’s not all. Unsterile needle use for intravenous heroin is associated with multiple, potentially deadly, infections such as hepatitis C and B, HIV/AIDS, syphilis, tetanus, septic thrombophlebitis, skin abscesses/cellulitis, brain abscesses, osteomyelitis, pneumonia and endocarditis.

The problem has been studied from every angle, but we are missing something that’s very important.

Addicted patients have been treated over the years, many hospital-based dual-diagnosis programs with appointments with support workers and in private practice.

In almost every case of addiction seen, regardless of the substance, pre-existing and undiagnosed conditions such as depression, anxiety or bipolar disorder. Usually, it’s these conditions that brought on the addictive behaviour in the first place.

But when a patient comes in for drug treatment, he or she gets treatment for his addiction and only addiction.

The traditional addiction model was summarized by Eric Nestler, M.D., Ph.D., in 2013: “At its core, addiction involves a biological process: the ability of repeated exposure to a drug of abuse to induce changes in a vulnerable brain that drives the compulsive seeking and taking of drugs, and loss of control over drug use.” Generally, adolescence represents the most sensitive time for a still-developing brain to be susceptible to drug use.

Traditional addiction treatment couples programs such as detoxification with Alcohol Anonymous-style self-help groups. Over more than 80 years, these programs have rescued millions of lives worldwide. However, a scathing June 2012 report from the National Center on Addiction and Substance Abuse states that “51.8 per cent of (programs) don’t assess co-occurring mental health disorders.”


Addiction treatment programs commonly miss that individuals attempt to “drown out” varying degrees of misery using alcohol and/or other drugs. Misery triggers addiction with a phenomenon known as “self-medication.” Mind states such as depression, anxiety, irritability and impulsivity can result from pre-existing and undiagnosed mood, anxiety and/or attention-deficit/hyperactivity disorder, causing pain that the sufferer tries to numb with drugs, including alcohol.

Usually, multiple addictions and disorders are present in every patient and addicted individuals are rarely aware of these underlying disorders.

Self-medication addiction treatment includes diagnosis of these pre-existing disorders, appropriate medication use and individual talking therapy, supplemented by (with informed consent) couples, marital or family therapy.

The comprehensive dual-diagnosis model and treatment integrate the “traditional” and “self-medication” models and treatments. Both are necessary to understand and treat addiction.

Pre-existing and undiagnosed disorders should be searched for as part of every evaluation of every addicted person, adolescent, adult or elderly. It is as much a mistake to treat the addictions and ignore the underlying disorders as it would be to treat the underlying disorders and ignore the addictions.

It’s a problem that can start young and last a lifetime.


A recent study determined that one in four Americans who began using any addictive substance before age 18 became addicted, compared to 1 in 25 Americans who started using at age 21 or older. Thus, parents need to frequently tell their children and adolescents not to begin smoking, drinking or using other drugs. Fear of upsetting parents is the biggest reason kids don’t use drugs.

But this is not a problem for drug treatment specialists alone. Approximately 80 per cent of Americans go to primary care practitioners – physicians, nurse practitioners, physician assistants – and receive an evaluation for addiction and treatment when needed.

These practitioners should additionally identify and treat these underlying mental health disorders or refer their patients to addiction and psychiatric physicians to do so. If pre-existing mental health disorders still remain undiagnosed, then addictions will likely worsen.

How many more millions of lives could be rescued, worldwide, if only the comprehensive dual-diagnosis model and treatment, described above, became routinely implemented by health care professionals?

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