01 - 20.1 Introduction and Overview

20.1 Introduction and Overview

Substance Use and Addictive Disorders 20.1 Introduction and Overview The most commonly used drugs have been part of human existence for thousands of years. For example, opium has been used for medicinal purposes for at least 3,500 years, references to cannabis (marijuana) as a medicinal can be found in ancient Chinese herbals, wine is mentioned frequently in the Bible, and the natives of the Western Hemisphere smoked tobacco and chewed coca leaves. As new drugs were discovered and new routes of administration developed, new problems related to their use emerged. Substance use disorders are complicated psychiatric conditions and like other psychiatric disorders, both biological factors and environmental circumstances are etiologically significant. This chapter covers substance dependence and substance abuse with descriptions of the clinical phenomena associated with the use of 11 designated classes of pharmacological agents: alcohol; amphetamines or similarly acting agents; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; phencyclidine (PCP) or similar agents; and a group that includes sedatives, hypnotics, and anxiolytics. A residual 12th category includes a variety of agents not in the 11 designated classes, such as anabolic steroids and nitrous oxide. TERMINOLOGY Various terms have been used over the years to refer to drug abuse. For example, the term dependence has been and is used in one of two ways when discussing substance use disorders. In behavioral dependence, substance-seeking activities and related evidence of pathological use patterns are emphasized, whereas physical dependence refers to the physical (physiological) effects of multiple episodes of substance use. Psychological dependence, also referred to as habituation, is characterized by a continuous or intermittent craving (i.e., intense desire) for the substance to avoid a dysphoric state. Behavioral, physical, and psychological dependence are the hallmark of substance use disorders. Somewhat related to dependence are the related words addiction and addict. The word addict has acquired a pejorative connotation that ignores the concept of substance abuse as a medical disorder. Addiction has also been trivialized in popular usage, as in the terms TV addiction and money addiction; however, the term still has value. There are common neurochemical and neuroanatomical substrates found among all addictions, whether it is to substances or to gambling, sex, stealing, or eating. These various

addictions may have similar effects on the activities of specific reward areas of the brain, such as the ventral tegmental area, the locus ceruleus, and the nucleus accumbens. Other Terms Codependence. The terms coaddiction and, more commonly, codependency or codependence are used to designate the behavioral patterns of family members who have been significantly affected by another family member’s substance use or addiction. The terms have been used in various ways and no established criteria for codependence exist. Enabling. Enabling was one of the first, and more agreed on, characteristics of codependence or coaddiction. Sometimes, family members feel that they have little or no control over the enabling acts. Either because of the social pressures for protecting and supporting family members or because of pathological interdependencies, or both, enabling behavior often resists modification. Other characteristics of codependence include unwillingness to accept the notion of addiction as a disease. The family members continue to behave as if the substance-using behavior were voluntary and willful (if not actually spiteful), and the user cares more for alcohol and drugs than for family members. This results in feelings of anger, rejection, and failure. In addition to those feelings, family members may feel guilty and depressed because addicts, in an effort to deny loss of control over drugs and to shift the focus of concern away from their use, often try to place the responsibility for such use on other family members, who often seem willing to accept some or all of it. Denial. Family members, as with the substance users themselves, often behave as if the substance use that is causing obvious problems were not really a problem; that is, they engage in denial. The reasons for the unwillingness to accept the obvious vary. Sometimes denial is self-protecting, in that the family members believe that if a drug or alcohol problem exists, then they are responsible. As with the addicts themselves, codependent family members seem unwilling to accept the notion that outside intervention is needed and, despite repeated failures, continue to believe that greater willpower and greater efforts at control can restore tranquility. When additional efforts at control fail, they often attribute the failure to themselves rather than to the addict or the disease process, and along with failure come feelings of anger, lowered self-esteem, and depression. A summary of some key terms related to substance use disorders is given in Table 20.1-1. Table 20.1-1 Terms Used in Substance-Related Disorders

EPIDEMIOLOGY The National Institute of Drug Abuse (NIDA) and other agencies, such as the National Survey of Drug Use and Health (NSDUH), conduct periodic surveys of the use of illicit drugs in the United States. As of 2012, it is estimated that more than 22 million persons older than the age of 12 years (about 10 percent of the total US population) were classified as having a substance-related disorder. Of this group, almost 15 million were dependent on, or abused, alcohol (Fig. 20.1-1). FIGURE 20.1-1 Substance dependence or abuse in the past year among persons age 12 or over: 2002– 2012. (From Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH

Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.) Figure 20.1-2 shows data from the surveys on the percentage of respondents who reported using various drugs. In 2012, 669,000 persons were dependent on, or abused, heroin; 1.7 percent (4.3 million) abused marijuana; 0.4 percent (1 million) abused cocaine; and 2 million were classified as dependent on, or abuse of, pain relievers. FIGURE 20.1-2 Dependence on, or abuse of, specific illicit drugs within the past year among persons age 12 or older: 2010. (From Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.) With regard to age at first use, those who started to use drugs at an earlier age (14 years or younger) were more likely to become addicted than those who started at a later age. This applied to all substances of abuse, but particularly to alcohol. Among adults aged 21 or older who first tried alcohol at age 14 or younger, 15 percent were classified as alcoholics compared with only 3 percent who first used alcohol at age 21 or older. Rates of abuse also varied according to age (Table 20.1-2). In 2012, the rate for dependence or abuse is highest among adults age 18 to 25 (19 percent) compared to youths age 12 to 17 (6 percent) and adults age 26 or older (7 percent). After age 21, a general decline occurred with age. By age 65, only about 1 percent of persons have used an illicit substance within the past year, which lends credence to the clinical observation that addicts tend to “burn out” as they age. Table 20.1-2 Illicit Drug Use in Lifetime, Past Year, and Past Month, by Detailed Age

Category: Percentages, 2011 and 2012 Table 20.1-3 summarizes data about the demographic characteristics of those who use illicit drugs. More men than women use drugs; the highest lifetime rate is among American Indian or Alaska Natives; whites are more affected than blacks or African Americans; those with some college education use more substances than those with less education; and the unemployed have higher rates that those with either part-time or fulltime employment. Table 20.1-3 Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 18 or Older, by Demographic Characteristics: Percentages, 2011 and 2012

Rates of substance dependence or abuse varied by region in the United States. In 2010, rates were slightly higher in the West (9 percent) and Midwest (9 percent) than in the Northeast (8 percent) and South (8 percent). Rates were similar in small metropolitan counties and large metropolitan counties (both at 9 percent) and were lowest in completely rural counties (7 percent). Rates are also higher among persons on parole or on supervised release from jail (34 percent vs. 9 percent). The number of persons driving while under the influence of drugs or alcohol is on a decline. The percentage driving under the influence of alcohol decreased from 14 percent in 2002 to

11 percent in 2010, and those driving under the influence of drugs decreased from 5 percent to 4 percent during the same period. A comprehensive survey of drug use and trends in the United States is available at www.samhsa.gov. ETIOLOGY The model of substance use disorders is the result of a process in which multiple interacting factors influence drug-using behavior and the loss of judgment with respect to decisions about using a given drug. Although the actions of a given drug are critical in the process, it is not assumed that all people who become dependent on the same drug experience its effects in the same way or are motivated by the same set of factors. Furthermore, it is postulated that different factors may be more or less important at different stages of the process. Thus, drug availability, social acceptability, and peer pressures may be the major determinants of initial experimentation with a drug, but other factors, such as personality and individual biology, probably are more important in how the effects of a given drug are perceived and the degree to which repeated drug use produces changes in the central nervous system (CNS). Still other factors, including the particular actions of the drug, may be primary determinants of whether drug use progresses to drug dependence, whereas still others may be important influences on the likelihood that drug use (1) leads to adverse effects or (2) to successful recovery from dependence. It has been asserted that addiction is a “brain disease,” that the critical processes that transform voluntary drug-using behavior to compulsive drug use are changes in the structure and neurochemistry of the brain of the drug user. Sufficient evidence now indicates that such changes in relevant parts of the brain do occur. The perplexing and unanswered question is whether these changes are both necessary and sufficient to account for the drug-using behavior. Many argue that they are not, that the capacity of drug-dependent individuals to modify their drug-using behavior in response to positive reinforcers or aversive contingencies indicates that the nature of addiction is more complex and requires the interaction of multiple factors. Figure 20.1-3 illustrates how various factors might interact in the development of drug dependence. The central element is the drug-using behavior itself. The decision to use a drug is influenced by immediate social and psychological situations as well as by the person’s more remote history. Use of the drug initiates a sequence of consequences that can be rewarding or aversive and which, through a process of learning, can result in a greater or lesser likelihood that the drug-using behavior will be repeated. For some drugs, use also initiates the biological processes associated with tolerance, physical dependence, and (not shown in the figure) sensitization. In turn, tolerance can reduce some of the adverse effects of the drug, permitting or requiring the use of larger doses, which then can accelerate or intensify the development of physical dependence. Above a certain threshold, the aversive qualities of a withdrawal syndrome provide a distinct recurrent motive for further drug use. Sensitization of motivational systems can increase the salience of drug-related stimuli.

FIGURE 20.1-3 World Health Organization schematic model of drug use and dependence. (From Edwards G, Arif A, Hodgson R. Nomenclature and classification of drug-and alcoholrelated problems. A WHO memorandum. Bull WHO. 1981;59:225, with permission.) Psychodynamic Factors The range of psychodynamic theories about substance abuse reflects the various popular theories during the last 100 years. According to classic theories, substance abuse is a masturbatory equivalent (some heroin users describe the initial “rush” as similar to a prolonged sexual orgasm), a defense against anxious impulses, or a manifestation of oral regression (i.e., dependency). Recent psychodynamic formulations relate substance use as a reflection of disturbed ego functions (i.e., the inability to deal with reality). As a form of self-medication, alcohol may be used to control panic, opioids to diminish anger, and amphetamines to alleviate depression. Some addicts have great difficulty recognizing their inner emotional states, a condition called alexithymia (i.e., being unable to find words to describe their feelings). Learning and Conditioning. Drug use, whether occasional or compulsive, can be viewed as behavior maintained by its consequences. Drugs can reinforce antecedent behaviors by terminating some noxious or aversive state such as pain, anxiety, or depression. In some social situations, the drug use, apart from its pharmacological effects, can be reinforcing if it results in special status or the approval of friends. Each use of the drug evokes rapid positive reinforcement, either as a result of the rush (the drug-induced euphoria), alleviation of disturbed affects, alleviation of withdrawal

symptoms, or any combination of these effects. In addition, some drugs may sensitize neural systems to the reinforcing effects of the drug. Eventually, the paraphernalia (needles, bottles, cigarette packs) and behaviors associated with substance use can become secondary reinforcers, as well as cues signaling availability of the substance, and in their presence, craving or a desire to experience the effects increases. Drug users respond to the drug-related stimuli with increased activity in limbic regions, including the amygdala and the anterior cingulate. Such drug-related activation of limbic areas has been demonstrated with a variety of drugs, including cocaine, opioids, and cigarettes (nicotine). Of interest, the same regions activated by cocainerelated stimuli in cocaine users are activated by sexual stimuli in both normal controls and cocaine users. In addition to the operant reinforcement of drug-using and drug-seeking behaviors, other learning mechanisms probably play a role in dependence and relapse. Opioid and alcohol withdrawal phenomena can be conditioned (in the Pavlovian or classic sense) to environmental or interoceptive stimuli. For a long time after withdrawal (from opioids, nicotine, or alcohol), the addict exposed to environmental stimuli previously linked with substance use or withdrawal may experience conditioned withdrawal, conditioned craving, or both. The increased feelings of craving are not necessarily accompanied by symptoms of withdrawal. The most intense craving is elicited by conditions associated with the availability or use of the substance, such as watching someone else use heroin or light a cigarette or being offered some drug by a friend. Those learning and conditioning phenomena can be superimposed on any preexisting psychopathology, but preexisting difficulties are not required for the development of powerfully reinforced substance-seeking behavior. Genetic Factors Strong evidence from studies of twins, adoptees, and siblings brought up separately indicates that the cause of alcohol abuse has a genetic component. Many less conclusive data show that other types of substance abuse or substance dependence have a genetic pattern in their development. Researchers recently have used restriction fragment length polymorphism (RFLP) in the study of substance abuse and substance dependence, and associations to genes that affect dopamine production have been postulated. Neurochemical Factors Receptors and Receptor Systems. With the exception of alcohol, researchers have identified particular neurotransmitters or neurotransmitter receptors involved with most substances of abuse. Some researchers base their studies on such hypotheses. The opioids, for example, act on opioid receptors. A person with too little endogenous opioid activity (e.g., low concentrations of endorphins) or with too much activity of an endogenous opioid antagonist may be at risk for developing opioid dependence. Even in a person with completely normal endogenous receptor function and neurotransmitter

concentration, the long-term use of a particular substance of abuse may eventually modulate receptor systems in the brain so that the presence of the exogenous substance is needed to maintain homeostasis. Such a receptor-level process may be the mechanism for developing tolerance within the CNS. Demonstrating modulation of neurotransmitter release and neurotransmitter receptor function has proved difficult, however, and recent research focuses on the effects of substances on the second-messenger system and on gene regulation. Pathways and Neurotransmitters The major neurotransmitters possibly involved in developing substance abuse and substance dependence are the opioid, catecholamine (particularly dopamine), and γaminobutyric acid (GABA) systems. The dopaminergic neurons in the ventral tegmental area are particularly important. These neurons project to the cortical and limbic regions, especially the nucleus accumbens. This pathway is probably involved in the sensation of reward and may be the major mediator of the effects of such substances as amphetamine and cocaine. The locus ceruleus, the largest group of adrenergic neurons, probably mediates the effects of the opiates and the opioids. These pathways have collectively been called the brain-reward circuitry. COMORBIDITY Comorbidity is the occurrence of two or more psychiatric disorders in a single patient at the same time. A high prevalence of additional psychiatric disorders is found among persons seeking treatment for alcohol, cocaine, or opioid dependence; some studies have shown that up to 50 percent of addicts have a comorbid psychiatric disorder. Although opioid, cocaine, and alcohol abusers with current psychiatric problems are more likely to seek treatment, those who do not seek treatment are not necessarily free of comorbid psychiatric problems; such persons may have social supports that enable them to deny the impact that drug use is having on their lives. Two large epidemiological studies have shown that even among representative samples of the population, those who meet the criteria for alcohol or drug abuse and dependence (excluding tobacco dependence) are also far more likely to meet the criteria for other psychiatric disorders also. In various studies, a range of 35 to 60 percent of patients with substance abuse or substance dependence also meets the diagnostic criteria for antisocial personality disorder. The range is even higher when investigators include persons who meet all the antisocial personality disorder diagnostic criteria, except the requirement that the symptoms started at an early age. That is, a high percentage of patients with substance abuse or substance dependence diagnoses have a pattern of antisocial behavior, whether it was present before the substance use started or developed during the course of the substance use. Patients with substance abuse or substance dependence diagnoses who have antisocial personality disorder are likely to use more illegal substances; to have more psychopathology; to be less satisfied with their lives; and to be more impulsive, isolated, and depressed than patients with antisocial personality disorders alone.

Depression and Suicide. Depressive symptoms are common among persons diagnosed with substance abuse or substance dependence. About one third to one half of all those with opioid abuse or opioid dependence and about 40 percent of those with alcohol abuse or alcohol dependence meet the criteria for major depressive disorder sometime during their lives. Substance use is also a major precipitating factor for suicide. Persons who abuse substances are about 20 times more likely to die by suicide than the general population. About 15 percent of persons with alcohol abuse or alcohol dependence have been reported to commit suicide. This frequency of suicide is second only to the frequency in patients with major depressive disorder. DIAGNOSTIC CLASSIFICATION There are four major diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5): (1) Substance Use Disorder; (2) Substance Intoxication; (3) Substance Withdrawal; and (4) Substance-Induced Mental Disorder. Substance Use Disorder Substance use disorder is the diagnostic term applied to the specific substance abused (e.g., alcohol use disorder, opioid use disorder) that results from the prolonged use of the substance. The following points should be considered in making this diagnosis. These criteria apply to all substances of abuse. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
4. tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance
5. withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance b. the same (or a closely related) substance is taken to relieve or avoid withdrawal

symptoms 6. the substance is often taken in larger amounts or over a longer period than was intended 7. there is a persistent desire or unsuccessful efforts to cut down or control substance use 8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 9. important social, occupational, or recreational activities are given up or reduced because of substance use 10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 11. craving or a strong desire or urge to use a specific substance. Substance Intoxication Substance intoxication is the diagnosis used to describe a syndrome (e.g., alcohol intoxication or simple drunkenness) characterized by specific signs and symptoms resulting from recent ingestion or exposure to the substance. A general description of substance intoxication includes the following points: The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance. Note: Different substances may produce similar or identical syndromes. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Substance Withdrawal Substance withdrawal is the diagnosis used to describe a substance specific syndrome that results from the abrupt cessation of heavy and prolonged use of a substance (e.g., opioid withdrawal). A general description of substance withdrawal requires the following criteria to be met: The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better

accounted for by another mental disorder. In the discussion of each substance in the sections that follow, the generic tables listed above, derived from the DSM-5 can be applied. Thus, in place of the word substance, the clinician should indicate the specific substance or drug that is used or that caused intoxication or withdrawal. TREATMENT AND REHABILITATION Some persons who develop substance-related problems recover without formal treatment, especially as they age. For those patients with less severe disorders, such as nicotine addiction, relatively brief interventions are often as effective as more intensive treatments. Because these brief interventions do not change the environment, alter druginduced brain changes, or provide new skills, a change in the patient’s motivation (cognitive change) probably has the best impact on the drug-using behavior. For those individuals who do not respond or whose dependence is more severe, a variety of interventions described below appear to be effective. It is useful to distinguish among specific procedures or techniques (e.g., individual therapy, family therapy, group therapy, relapse prevention, and pharmacotherapy) and treatment programs. Most programs use a number of specific procedures and involve several professional disciplines as well as nonprofessionals who have special skills or personal experience with the substance problem being treated. The best treatment programs combine specific procedures and disciplines to meet the needs of the individual patient after a careful assessment. No classification system is generally accepted for either the specific procedures used in treatment or programs using various combinations of procedures. This lack of standardized terminology for categorizing procedures and programs presents a problem, even when the field of interest is narrowed from substance problems in general to treatment for a single substance, such as alcohol, tobacco, or cocaine. Except in carefully monitored research projects, even the definitions of specific procedures (e.g., individual counseling, group therapy, and methadone maintenance) tend to be so imprecise that usually just what transactions are supposed to occur cannot be inferred. Nevertheless, for descriptive purposes, programs are often broadly grouped on the basis of one or more of their salient characteristics: whether the program is aimed at merely controlling acute withdrawal and consequences of recent drug use (detoxification) or is focused on longer-term behavioral change; whether the program makes extensive use of pharmacological interventions; and the degree to which the program is based on individual psychotherapy, Alcoholics Anonymous (AA) or other 12-step principles, or therapeutic community principles. For example, government agencies recently categorized publicly funded treatment programs for drug dependence as (1) methadone maintenance (mostly outpatient), (2) outpatient drug-free programs, (3) therapeutic communities, or (4) short-term inpatient programs. Selecting a Treatment

Not all interventions are applicable to all types of substance use or dependence, and some of the more coercive interventions used for illicit drugs are not applicable to substances that are legally available, such as tobacco. Addictive behaviors do not change abruptly, but through a series of stages. Five stages in this gradual process have been proposed: precontemplation, contemplation, preparation, action, and maintenance. For some types of addictions the therapeutic alliance is enhanced when the treatment approach is tailored to the patient’s stage of readiness to change. Interventions for some drug use disorders may have a specific pharmacological agent as an important component; for example, disulfiram, naltrexone (ReVia), or acamprosate for alcoholism; methadone (Dolophine), levomethadyl acetate (ORLAAM), or buprenorphine (Buprenex) for heroin addiction; and nicotine delivery devices or bupropion (Zyban) for tobacco dependence. Not all interventions are likely to be useful to health care professionals. For example, many youthful offenders with histories of drug use or dependence are now remanded to special facilities (boot camps); other programs for offenders (and sometimes for employees) rely almost exclusively on the deterrent effect of frequent urine testing; and a third group are built around religious conversion or rededication in a specific religious sect or denomination. In contrast to the numerous studies suggesting some value for brief interventions for smoking and for problem drinking, few controlled studies are conducted of brief interventions for those seeking treatment for dependence on illicit drugs. In general, brief interventions (e.g., a few weeks of detoxification, whether in or out of a hospital) used for persons who are severely dependent on illicit opioids have limited effect on outcome measured a few months later. Substantial reductions in illicit drug use, antisocial behaviors, and psychiatric distress among patients dependent on cocaine or heroin are much more likely following treatment lasting at least 3 months. Such a time-in-treatment effect is seen across very different modalities, from residential therapeutic communities to ambulatory methadone maintenance programs. Although some patients appear to benefit from a few days or weeks of treatment, a substantial percentage of users of illicit drugs drop out (or are dropped) from treatment before they have achieved significant benefits. Some of the variance in treatment outcomes can be attributed to differences in the characteristics of patients entering treatment and by events and conditions following treatment. Programs based on similar philosophical principles and using what seem to be similar therapeutic procedures vary greatly in effectiveness, however. Some of the differences among programs that seem to be similar reflect the range and intensity of services offered. Programs with professionally trained staffs that provide more comprehensive services to patients with more severe psychiatric difficulties are more likely able to retain those patients in treatment and help them make positive changes. Differences in the skills of individual counselors and professionals can strongly affect outcomes. Such generalizations concerning programs serving illicit drug users may not hold for programs dealing with those seeking treatment for alcohol, tobacco, or even cannabis problems uncomplicated by heavy use of illicit drugs. In such cases, relatively brief

periods of individual or group counseling can produce long-lasting reductions in drug use. The outcomes usually considered in programs dealing with illicit drugs have typically included measures of social functioning, employment, and criminal activity, as well as decreased drug-using behavior. Treatment of Comorbidity Treatment of the severely mentally ill (primarily those with schizophrenia and schizoaffective disorders) who are also drug dependent continues to pose problems for clinicians. Although some special facilities have been developed that use both antipsychotic drugs and therapeutic community principles, for the most part, specialized addiction agencies have difficulty treating these patients. Generally, integrated treatment in which the same staff can treat both the psychiatric disorder and the addiction is more effective than either parallel treatment (a mental health and a specialty addiction program providing care concurrently) or sequential treatment (treating either the addiction or the psychiatric disorder first and then dealing with the comorbid condition). Services and Outcome The extension of managed care into the public sector has produced a major reduction in the use of hospital-based detoxification and virtual disappearance of residential rehabilitation programs for alcoholics. Managed-care organizations, however, tend to assume that the relatively brief courses of outpatient counseling that are effective with private-sector alcoholic patients are also effective with patients who are dependent on illicit drugs and who have minimal social supports. For the present, the trend is to provide the care that costs the least over the short term and to ignore studies showing that more services can produce better long-term outcomes. Treatment is often a worthwhile social expenditure. For example, treatment of antisocial illicit drug users in outpatient settings can decrease antisocial behavior and reduce rates of human immunodeficiency virus (HIV) seroconversion that more than offset the treatment cost. Treatment in a prison setting can decrease post-release costs associated with drug use and rearrests. Despite such evidence, problems exist in maintaining public support for treatment of substance dependence in both the public and private sectors. This lack of support suggests that these problems continue to be viewed, at least in part, as moral failings rather than as medical disorders. REFERENCES Bonder BR. Substance-related disorders. In: Bonder BR. Psychopathology and Function. 4thed. Thorofare, NJ: SLACK Inc.; 2010:103. Clark R, Samnaliev M, McGovern MP. Impact of substance disorders on medical expenditures for Medicaid beneficiaries with behavioral health disorders. Psychiatr Serv. 2009;60:35. Ersche KD, Jones PS, Williams GB, Turton AJ, Robbins TW, Bullmore ET: Abnormal brain structure implicated in